Grains and Starches

The Purple Peruvian Potato

Most people have no trouble digesting complex carbohydrates in the forms of starchy or fibrous vegetables, fruits, or whole-grains. But for those of us with CF, digestive issues, diabetes, or dysbiosis, complex carbohydrate digestion can be problematic. Certain compounds in complex carbohydrates can be irritating and can cause unwanted bacterial fermentation that may lead to digestive upset, as well as contribute to a wide range of other symptoms including neurological/psychological dysfunction, allergies, autoimmunity, systemic inflammation, increased susceptibility to infections, and increased respiratory mucus production. For those of use with dysbiosis or compromised digestion, being more conscious of our carbohydrate consumption is a very important step towards healing our gut.

A Change in Diet TheoryUntil recently, I believed that in order to correct dysbiosis, restricting carbohydrates for an extended period of time was a required part of the protocol in all situations. I believed that it was necessary for all people with dysbiosis to use an elimination diet that restricted carbs like GAPS or SCD. But the more research I did, the more I realized that this one-size-fits-all approach is not appropriate for long term use and needs to be used with adjunct therapies in order to be effective. The GAPS, SCD, and FODMAPs diets all restrict certain types of complex carbohydrates contained in fibrous plant material such as those in grains, fruits, and vegetables in order to address dysbiosis and its associated symptoms. The goal of the GAPS and SCD is to severely restrict carbohydrate consumption over a period of weeks or months so that the pathogenic bacteria in the gut are starved out and their populations decimated. These diets then follow up with a period of replacing those bad bacteria with good bacteria in the form of probiotic supplements and/or fermented foods, and slowly reintroduce plant fibers over a period of weeks or months. The FODMAPs diet does not aim to starve out pathogenic bacteria, but simply tries to remove the fermentable substrates that pathogenic bacteria use to proliferate and cause digestive symptoms. However, all of these 3 diets have the same unintended consequence: they starve out good bacteria populations along with the pathogenic populations, reducing overall intestinal microbiota diversity. As we've discussed before, beneficial gut bacteria depend on plant fiber to ferment upon and produce immune-stimulating compounds and short-chain fatty acids that directly feed our intestinal cells. A healthy population of good bacteria also provides competitive defenses against infection by pathogenic species. Thus, these diets should not be used for more than a few weeks without the use of complementary therapies to kill pathogenic flora, such as antimicrobial herbs or specific antibiotics, such as rifaximin. Recent research and clinical experience has shown that the GAPS/SCD/FODMAPs diet approaches are not effective in correcting dysbiosis by themselves, though they may be used in the short-term to manage digestive symptoms [1]. In fact, it may be even more effective to maintain an adequate level of complex carbohydrates in the diet during the "killing" phase of a gut-healing protocol because bacteria are most effectively targeted by antimicrobial herbs and drugs when they are proliferating [2]. Bacteria and other pathogens that are stressed via starvation or other means have the ability to go dormant (similar to hibernation) in order to preserve their reproductive capacities for less stressful times. Many herbs and antibiotics target bacteria's reproductive processes, so if these bacteria stop reproducing and go dormant, the antimicrobials may be ineffective at clearing the infection. Recent clinical experience seems to indicate that feeding the pathogenic flora with carbs and FODMAPs (if tolerable for the individual) while at the same time hitting them hard with antimicrobial herbs is the most effective treatment plan with the lowest recurrence rate.

All cases of dysbiosis are different, but for many types of dysbiosis the most effective way to combat it is with a multi-week (at least 2-3 week) course of antimicrobial herbs (herbs are shown to be as or more effective than the leading antibiotics used for dysbiosis) alongside a whole-food Paleo-like diet that maximizes plants and minimizes inflammatory foods. After that is a period of using gut-healing herbs (like marshmallow, meadowsweet, calendula, comfrey) and foods (bone broth, l-glutamine, gelatin, good fats and proteins) that will help restore proper gut permeability and heal the leaky gut. During this stage it is absolutely critical to correct whatever imbalance there may be in digestive secretions (such as low stomach acid) that may have contributed to the development of the dysbiosis in the first place. At the same time probiotics (supplements and foods) and prebiotic fibers (in vegetables and herbs like burdock root, flax seeds, dandelion root, marshmallow root, etc.) are added back into the diet slowly, helping to re-establish a healthy gut ecology. The Paleo-like diet is maintained as long as possible, and can allow for foods to be slowly added back into the diet according to the person's tolerance (but those inflammatory foods like sugar, wheat, junk food, and inflammatory oils will always be avoided).

Starchy, Fibrous Vegetables and FODMAPsAs I mentioned, reducing fibers, starches and FODMAPs in the diet is only useful if trying to manage digestive symptoms in the short term, but will not correct the root cause of the issue, which is dysbiosis. Nonetheless, it is worth mentioning here some resources for learning more about these carbohydrate-restrictive diets. On the GAPS (Gut and Psychology Syndrome) diet or SCD (Specific Carbohydrate Diet) certain fruits and vegetables (as well as most sweeteners and other carbohydrates) are restricted based upon their starch and fiber content in order to minimize bacterial fermentation. During the initial phases of these diets, some starchy vegetables such as root vegetables (potatoes, sweet potatoes, parsnips, arrowroot, etc.) are on the "no" list, as well as many fruits and fruit juices. "Legal" starches include carrots, pumpkins, winter squashes, and beets. For a full list of the foods that are "legal" or "illegal" on the gut-healing regime according to the SCD, click here. The FODMAPs diet (which stands for Fermentable Oligo-, Di-, Mono-saccharides, and Polyols) eliminates many commonly used fruits, vegetables, and grains from the diet based upon their complex carbohydrate content. The rules are a bit more complicated than the GAPS/SCD, so if you are interested in learning more read this for a more detailed explanation. Here is a helpful chart of foods allowed and not allowed on the FODMAPs diet.

Once the dysbiosis has been addressed and complex carbs/FODMAPs are no longer causing any issues, consider preparing starchy vegetables like potatoes in a way that increases their prebiotic content. In Jo Robinson's book Eating on the Wild Side, she explains that by refrigerating or freezing potatoes for at least 24 hours after they've been cooked, you can reduce their glycemic load by returning the starches that have been converted to simple sugars with cooking back into resistant starch, which is a kind of prebiotic fiber. This can help mitigate any blood sugar spikes that potatoes may be want to cause, and also increases their capacity to feed your friendly gut bugs! A cheap and easy way to increase the amount of prebiotic resistant starch in the diet is to add raw potato starch to smoothies, shakes, and other creamy-cold foods. To read more about this, click here.

Issues with GrainBesides containing complex carbohydrates (including FODMAPs) that can feed bacterial fermentation (good and bad), grains contain some compounds that can be irritating to our digestive systems if they are not properly prepared in the traditional ways used by our ancestors for thousands of years [3]. Humans haven't been eating grains all that long. From an evolutionary perspective, the Agricultural Revolution (which introduced the cultivation of grains about 10,000 years ago) was just last week. Depending on your genetic heritage and how long ago your ancestors started eating grains, you may tolerate grains better or worse than your friends or neighbors. Generally, those with ancestry from the early-adopting places like the Middle East, central Europe, and Asia have a better time digesting grains than those from most other late-adopting places such as the Americas, Africa, Melanesia, or even the British Isles (Northeastern Europe and the British Isles only adopted agriculture - and not uniformly - about 6,000 years ago) [4]. Even on the early-adopting continents, certain areas only had exposure to certain grains. For example, South America cultivated corn (maize) and the British Isles cultivated oats, but in these places exposure to wheat came much later (thus, their exposure to glutenous grains was minimal until then). Our ancestor's epigenetic exposure to grains and gluten generations ago may be a determining factor in the ability for us to digest them now. I am of Irish ancestry, and it turns out that wheat was not commonly used in Ireland until the 18th century [5]. From an evolutionary stand point, I highly doubt that this is enough time for my ancestors' guts to have developed a strong ability to digest the gluten in wheat. This may be why gluten intolerance is quite common among groups with Celtic ancestry. What's also interesting is that the CF gene is linked with Western and Northern European ancestry, and Western and Northern Europe had later exposures to grains and gluten. Keeping all this archeological/paleo-genetic information in mind might actually be helpful for determining which grains you may tolerate best, and there are many resources on the Weston A. Price website that provide information on specific traditional diets from all over the world and how they properly prepared their grains.

Grains are the seeds of grasses bred over many generations of human domestication to be larger and fatter than wild varieties, and to emphasize their sweetness and starchiness. But grains are very smart. They have a number of different mechanisms that they utilize to ensure that they maintain their viability in tough weather out in the field, and also to protect themselves against animal predation. With these mechanisms, a grain is hoping that even if you do eat it, its defenses will cause it to pass through you completely undigested, so that you will poop it out whole on the other side and it will still be able to seed itself in the ground and propagate another generation of grasses. Without proper preparation and cooking, these natural grain defenses are left intact and we are unable to fully digest and assimilate the grain. This is why all traditional societies that ate grains had very specific and complex ways of processing grains to remove the grain's defenses to ensure maximum digestibility. These methods of preparation all included a number of stages including soaking, germinating, sometimes sprouting, and controlled fermentation.

One of the biggest problems with grains is that they all contain phytic acid, to varying degrees depending on the species. Phytic acid occurs in the bran of a grain, and is the principal form of phosphorus storage in many plant tissues. When ingested, the arms of phytic acid molecule bind to minerals inside the body, chelating them and carrying them out in the stool. Therefore, not only is the phosphorus in an unprepared grain completely unavailable to animals with only one stomach (i.e. humans), but also ingestion of phytic acid inhibits our bodies' abilities to assimilate many essential minerals from our foods such as calcium, magnesium, iron, and zinc. Furthermore, phytic acid is also an enzyme-inhibitor, preventing our digestive enzymes (i.e. pepsin, amylase, and trypsin) from helping us break down our foods and allowing us to absorb them [6]. Another problematic part of a grain is lectin, which is also contained in the bran of whole grains. One purpose of lectins in grains is to act as a browsing deterrent to insects and so it can be sharp and shard-like, and in the guts if sensitive people can cause significant inflammation. Because of these and other irritating compounds in grains, some people are choosing to remove grains from their diets entirely and return to a more "paleolithic" (pre-agricultural style) diet of meat, animal fats, fruits and vegetables, tubers, and wild or wild-like plants. This is where the idea of the Paleo Diet comes in. It makes sense really, since many of us have a lifetime's-worth of digestive trauma from eating improperly prepared grains that we must recover from, so eliminating grains completely for an extended period can be very healing. After so many years of exposure to phytic acid, lectins, and highly-processed grain products, our guts need some time to heal and recover. Some people choose to stay off grains completely forever, some choose to reintroduce them gradually once they've learned how to properly prepare them using the methods outlined in Nourishing Traditions. Essentially all of the issues with grains (phytic acid, lectins, fermentable carbohydrates, etc.) are also true for legumes, so many people who cut out grains choose to gut out legumes as well. Legumes include beans, peas, soy, and peanuts.

The Gluten ProblemGluten is a protein that is the most common culprit implicated in grain sensitivites. Only some grains contain gluten, such as wheat (including spelt, einkorn, kamut, farro, and durum), barley, rye, and contaminated oats. Gluten-free grains include uncontaminated oats, millet, quinoa, buckwheat, corn, rice, sorghum, and teff. Gluten can become a problem when it is not properly broken down by traditional cooking methods (as described in Nourishing Traditions) and/or when the individual has inadequate digestive capabilities or dysbiosis/leaky gut syndrome. What often happens is that an individual develops a sensitivity to the gluten in wheat for one of the above reasons, and this sensitivity can lead the immune system to develop a cross-reactivity to the gluten contained in other grains. A significant amount of research and writing has been dedicated to the topic of gluten sensitivities and allergies, so if you want to learn more about this issue in detail I suggest you check out the works of Chris Kresser, Dr. Alessio Fasano, or Dr. William Davis' book Wheat Belly. If gluten causes a sensitivity that is left unaddressed and if there is also an underlying dysbiosis that causes increased gut permeability (i.e. leaky gut syndrome), then the immune system may begin to create antibodies against gluten so that every time you eat gluten, an allergic or autoimmune reaction results which can lead to severe digestive distress, systemic inflammation, or autoimmune tissue damage in other parts of the body.

The development of all autoimmune diseases (such as Celiac disease, Type 1 diabetes, and multiple sclerosis) is dependent upon certain precursors, not the least of which is increased intestinal permeability. We know that gliadin (a part of gluten) in wheat and other grain proteins called prolamins can cause the release of a human protein called zonulin, which is responsible for controlling intestinal permeability. When grain proteins binds to the zonulin receptor, zonulin is released, causing the junctions between the cells in the intestinal wall to loosen, allowing food and bacteria to pass through into the blood [7]. Furthermore, certain grain proteins are similar enough in structure to the proteins that make up certain tissues in the body that when the immune system attacks the "invading" grain protein that was mistakenly allowed into the blood, it also attacks whatever may look like that protein, even if it is your own cells! This is autoimmunity: when the body attacks itself in a misguided immune response. One example of this is type 1 diabetes (T1D), where "two independent studies tracking large cohorts of newborns at high risk for T1D showed that the odds ratio for developing the disease was 4- to 5-fold higher in subjects prematurely exposed (<3 months of age) to gluten" [8]. In other words, for some type 1 diabetics, the gluten in wheat has caused the body to develop auto-antibodies which trigger immune attacks against the islet cells in the pancreas, essentially destroying its ability to produce insulin. There are about 50 disease that are thought to be caused by autoimmunity, and all of them have some relation to abnormal intestinal permeability. Once a leaky gut is established, an auto-antibody can be created from a grain, legume, or dairy protein to attack a variety of human tissues causing joint pain, organ degeneration, degradation of the nerves, and other diseases [9]. In fact, one of the leading researchers in autoimmunity, Dr. Alessio Fasano, believes that leaky gut and dysbiosis are required as preconditions for the development of autoimmunity [10]. This is why Paleo and anti-inflammatory diets remove all grains, legumes, and dairy to eliminate the possible causes of any autoimmune disorders, even if they may yet be subclinical.

How to Properly Prepare GrainsI highly suggest you pick up a copy of Nourishing Traditions if you would like to keep grains in your diet because it is an absolute necessity that grains be properly soaked, germinated, and fermented to maximize their digestibility. Because whole grains still have the bran, they contain the most phytic acid and must be soaked and germinated for a number of days in order to remove it. Grains with the bran removed, such as white rice, have less phytic acid but they've been "killed" in processing so they cannot germinate. Whole grains are literally alive, and will sprout if you give them the right conditions. Sprouting grains not only breaks down their phytic acid, but also potentiates naturally-occuring enzymes (including phytase, which breaks down phytic acid) and many minerals that would not be bioavailable otherwise. Different grains need different soaking times and preparation methods, and this article gives some very detailed information on some of these grain-specific preparation methods. For some people, it might be too much of a hassle to properly prepare their grains, in which case it will be necessary to go Paleo.

I used to eat brown rice that I sprouted before cooking. I soaked the rice overnight for 12 hours, then drained it and let it sit to germinate (rinsing every 12 hours) for several days. When the grains start to show little white sprouts popping out (see below) I know they are ready to be cooked. I then put them into a pot or rice cooker and slow-cook them with a ratio of 1 cup rice to 2.5 cups water. After it has cooked, sometimes I would let the cooked rice sit on the stove overnight to let it ferment a little, which allows bacteria to break down some of the complex carbohydrates for me, making my job a little easier. You can do this until it tastes sour, if you'd like. Then it becomes probiotic! My sister loves to make soured millet.

Letting the rice germinate.

See the little sprouts!

Glycemic LoadIt is worth noting that grains have a significantly higher glycemic load than other whole food carbohydrates. I can no longer eat whole grains (not even my favorite, brown rice) anymore because it always spikes my blood sugar outrageously high no matter what I do. Potatoes, sweet potatoes, other starchy vegetables, and fruits do not have the same effect and are much easier to control my blood sugar with. Interestingly, processed whole grains (like brown rice pasta or rice cakes) are easier to control my blood sugar with. I don't know the cause of this phenomena, but others with CF-related diabetes have reported the same thing happens to them too. So whole grains should be used with extreme caution with people with glucose intolerance or diabetes. Mainstream dietary advice may even tell diabetics to eat whole grains as part of a "balanced diet", but this is bad advice. Diabetics should avoid grains completely if they cause wild swings in blood sugar, and should cautiously choose vegetable or fruit starches (like potatoes or squashes) instead. Some dietary advice for diabetics will tell you to avoid potatoes because their glycemic load is so high, but this is only true for white and yellow potatoes (like Russets). I have not found potatoes to be as problematic for me as grains.

How to BeginThe first step in embarking on a carbohydrate conscious diet is to eliminate all glutenous grains, especially modern wheat. These are the hardest grains to digest, and even people with "normal" digestive systems are developing sensitivities to them. At the very least, cutting out modern wheat (any wheat that is not spelt, einkorn, or kamut, which are the ancient varieties) is an absolute must. Modern wheat is so hybridized, genetically altered, and sprayed with chemicals that it is a very common allergen in the West (especially America). Because we've been so traumatized by the gluten in modern wheat, a lot of folks also develop sensitivities to the gluten in other grains, which the body detects as being very similar. So eliminating all gluten is the safest choice.

An important thing to note is that after you've been on an elimination diet or a cleaner diet (like Paelo) for some time you may notice that you've become much more sensitive to how foods make you feel, and you will even notice that foods you thought you could tolerate just fine before are now giving you digestive troubles. This may be disappointing, but it's actually a great sign that you've eliminated enough of the background irritation and inflammation in the gut that you can actually feel when things are going wrong - because it will be unusual for you to feel uncomfortable!

Using an elimination diet or a Paleo-like diet during and after addressing any potential dysbiosis is a very useful tool for discovering what you are or are not sensitive to. But be careful. In most cases it is a good idea to make big dietary changes when you are relatively healthy (i.e. not battling an acute infection or too underweight), and make sure that you are not just eliminating the "bad" foods but also replacing those them with "good" foods. This may seem obvious, but I actually did not think this through when I started the GAPS diet a few years ago. Carbohydrates are the main macronutrient that allows us to gain and maintain weight, so to cut them out without replacing them with alternatives can cause weight loss. This may be a good thing for those who are overweight but it is a bad thing for most CFers. I didn't give myself enough options for high calorie meals, and so I ended up just cutting out foods and so I ate a lot less and lost weight. Don't do this! Plan it out and think it through. Before making the big switch, practice making the meals and recipes that you will use on your new diet, to make sure it's easy enough to incorporate into your new routine. Meal planning is key when first starting out on a new diet. Add in new good foods before eliminating bad foods so that you always have a lot of choice when it comes to healthy meal options. ​